Arterial Line

Consent: Prior to performing the procedure, consent must be obtained from either the patient or a surrogate decision maker, and the proper consent form must be signed. Review the procedure, potential benefits, potential risks, and complications. 

Ultrasound Survey: You will cannulate the radial artery between the distal radius and the flexor carpi radialis tendon. Utilizing these landmarks and the linear probe, you will use the ultrasound to find an appropriate site of arterial cannulation. The probe marker should be facing YOUR left hand side. The vein will be compressible without any pulsation, and the artery will be pulsatile, thick walled, and non compressible.

Prep Patient: Raise the patient’s bed to an appropriate height to avoid hunching over during the procedure. Put the bed rail down at the side from which you will be performing the procedure. Place the patient’s wrist in the supine position (palm facing the ceiling) and extend the hand at the wrist to bring the radial artery closer to the skin surface. You can use a rolled up towel/cloth to prop under the patient’s hand to keep them positioned throughout the procedure (See image below). 

Sterilize: Place your bouffant cap on. Put on sterile gloves (see sterile approach tab for more detailed information). Ask an assistant to open the large chloraprep antiseptic swabsticks in a sterile fashion. Sterilize the cannulation site you located previously with at least 2 swabsticks, starting at the cannulation site and moving outwards in a circular manner for at least 2 min. Allow it to completely dry before starting the procedure. Discard your sterile gloves. 

Gown Up: Wash your hands. Put your sterile gown on (see sterile approach tab for more detailed information). Then, put a new pair of sterile gloves on. 

Prep Table and Kit: Using your assistant to open the packages, open up the half drape onto a table to create a sterile field. When prepping your table, align the items needed in order of how they are needed in the procedure to ensure the procedure goes smoothly (aka “mise en place”). You will first need your lidocaine, lidocaine syringe with blunt needle and anesthetizing needle, catheter which has the introducer needle and guidewire within the catheter (the black knob allows you to advance the guidewire, the white catheter tip allows you to advance the catheter), suture clip, suture, biopatch, dressing. 

Drape: The drape is included within the radial artery kit. Remove the sticker lining. Align the opening of the drape at the cannulation site and stick the drape onto the site.

Probe Cover: The probe cover can be found in the Universal dressing & PPE kit or can be found individually. When you open the probe cover kit, you will find the probe cover, 2 rubber bands, and sterile ultrasound gel. Ask your assistant to place non-sterile gel on the top of the linear probe, and hand you the probe. Place your hand in the inside of the probe cover, grab the linear probe from the assistant, and then slide the cover off of your hand and over the probe down the cord. Ask the assistant to grab the end of the probe cover to slide it all the way down towards the floor. Secure one rubber band on the probe and another one around the cord. Open the sterile gel and squeeze it onto a sterile area near the procedure site so it is available nearby.  

Time Out: Physician and RN will perform time out together in front of the patient. You will confirm the 3 P’s - proper patient, procedure, and location. Review allergies and confirm that informed consent was obtained. 

Anesthetize: Patient’s may need IV sedation in addition to local anesthetics prior to the procedure if the patient is altered and agitated, as it is dangerous for the patient to move during the procedure. You will also locally anesthetize the site using lidocaine. Open the lidocaine, swab the top of the lidocaine vial with an alcohol pad, and attach the blunt needle to the syringe. The blunt needle allows you to draw the lidocaine into the syringe as it has a bigger diameter, however, you cannot inject the patient using this needle. Once lidocaine is drawn into the syringe, change the blunt needle tip to the 22 to 25 gauge anesthetizing needle. Create a wheal at the site of insertion, however, aspirate prior to pushing lidocaine to ensure you are not in a vessel. 

Cannulate:

1. Position the needle: Using the ultrasound, confirm your cannulation site. Again, the probe marker should face towards YOUR left hand side. Thus, moving the needle right or left will correlate with the orientation of the ultrasound image (if you move your needle towards your left, the needle will move to the left hand side of the ultrasound image). Position the probe so that the vessel is in the middle of the screen. If you press the M mode once, you will see a vertical line in the middle of the screen which can help you align the vessel. If your vessel is aligned properly, when you insert the needle right where the vertical mark on the probe is, you will be directly above the vessel. Ensure that the needle is directly perpendicular to your probe marker (the length of the probe and the length of the needle should make a T). 

2. Cannulate: You will insert the needle at a 45 degree angle. Penetrate the skin. Then, slowly move your probe away from you until you see your needle tip. Either move your probe or your needle, do not move both at the same time. Once you see your needle tip, start to advance your needle until you can no longer visualize your needle tip on the screen. Now, advance your probe again away from you until you see your needle tip reappear. Repeat this process until you penetrate the vessel, see the needle tip within the center of the vessel lumen, and you have flashback of blood within your catheter. Now you may drop the probe. Flatten your needle angle. 

Guidewire: To advance the guidewire, without moving the needle, you will use your nondominant hand to slide the black knob at the distal end of the catheter towards the proximal end. 

Advancing catheter: Without moving the needle, advance the white catheter tip into the vessel, and then remove the needle (see image above). 

Connect: Obtain the arterial tubing from the nurse and screw it onto the newly placed catheter. Ensure the catheter is reading accurately with a proper arterial waveform. 

Secure: Clip the suture clip along the catheter (see image above) and suture the catheter at each end of the suture clip. Clean and dry the site, and then apply the sterile dressing

Document: Write a procedure note including any complications or medications given during the procedure

Consent: Prior to performing the procedure, consent must be obtained from either the patient or a surrogate decision maker, and the proper consent form must be signed. Review the procedure, potential benefits, potential risks, and complications. 

Ultrasound Survey:  You will cannulate the femoral artery just inferior to the inguinal ligament just lateral to the femoral vein. Utilizing these landmarks and the linear probe, you will use the ultrasound to find an appropriate site of cannulation. The probe marker should be facing YOUR left hand side. The vein will be compressible without any pulsation, and the artery will be pulsatile, thick walled, and non compressible. Track the vessels up and down, compressing at 3 different locations to ensure the site is without significant atherosclerosis. Find an appropriate site where the artery is not directly under or over the vein to avoid potential venous puncture during the procedure. 

Prep Patient: Raise the patient’s bed to an appropriate height to avoid hunching over during the procedure. Put the bed rail down at the side from which you will be performing the procedure. If the patient has a large pannus, tape the pannus upward and away by using the side rail on the opposite side of the bed to secure the tape. Avoid shaving the patient, as this increases the risk of site infection. 

Sterilize: Place your bouffant cap on. Put on sterile gloves (see sterile approach tab for more detailed information). Ask an assistant to open the large chloraprep antiseptic swabsticks in a sterile fashion. Sterilize the cannulation site you located previously with at least 2 swabsticks, starting at the cannulation site and moving outwards in a circular manner for at least 2 min. Allow it to completely dry before starting the procedure. Discard your sterile gloves. 

Gown Up: Wash your hands. Put your sterile gown on (see sterile approach tab for more detailed information). Then, put a new pair of sterile gloves on. 

Prep Table and Kit: Using your assistant to open the packages, open up the half drape onto a table to create a sterile field. When prepping your table, align the items needed in order of how they are needed in the procedure to ensure the procedure goes smoothly (aka “mise en place”). You will first need your lidocaine, lidocaine syringe with blunt needle and anesthetizing needle, introducer needle with syringe attached, guidewire, catheter, biopatch, suture material, and dressing. The guidewire’s tip is in a J position which makes it difficult to thread over the needle, thus, you will need to pull the tip slightly in to straighten the tip.

Drape:  Open the central line drape from the universal PPE kit (can also be used for femoral arterial line). The drape has arrows along with a body symbol to help you align the drape in the correct position. Remove the sticker lining. Align the opening of the drape at the cannulation site and stick the drape onto the site. Pull the top of the drape away from you, pull the next tab towards you, and the next two tabs towards the head and feet of the patient. 

Probe Cover: The probe cover can be found in the Universal dressing & PPE kit or can be found individually. When you open the probe cover kit, you will find the probe cover, 2 rubber bands, and sterile ultrasound gel. Ask your assistant to place non-sterile gel on the top of the linear probe, and hand you the probe. Place your hand in the inside of the probe cover, grab the linear probe from the assistant, and then slide the cover off of your hand and over the probe down the cord. Ask the assistant to grab the end of the probe cover to slide it all the way down towards the floor. Secure one rubber band on the probe and another one around the cord. Open the sterile gel and squeeze it onto a sterile area near the procedure site so it is available nearby.  

Time Out: Physician and RN will perform time out together in front of the patient. You will confirm the 3 P’s - proper patient, procedure, and location. Review allergies and confirm that informed consent was obtained. 

Anesthetize: Patient’s may need IV sedation in addition to local anesthetics prior to the procedure if the patient is altered and agitated, as it is dangerous for the patient to move during the procedure. You will also locally anesthetize the site using lidocaine. Open the lidocaine, swab the top of the lidocaine vial with an alcohol pad, and attach the blunt needle to the syringe. The blunt needle allows you to draw the lidocaine into the syringe as it has a bigger diameter, however, you cannot inject the patient using this needle. Once lidocaine is drawn into the syringe, change the blunt needle tip to the 22 or 25 gauge anesthetizing needle. Create a wheal at the site of insertion, however, aspirate prior to pushing lidocaine to ensure you are not in a vessel. Then, insert your needle vertically into the insertion site, aspirate to ensure no blood return, push medication, advance needle and repeat. Do this until you are closer to the depth of insertion required to cannulate the vessel (keep in mind the depth the vessel was at during initial ultrasound survey). 

Position the needle: Using the ultrasound, confirm your cannulation site. Again, the probe marker should face towards YOUR left hand side. Thus, moving the needle right or left will correlate with the orientation of the ultrasound image (if you move your needle towards your left, the needle will move to the left hand side of the ultrasound image). Position the probe so that the vessel is in the middle of the screen. If you press the M mode once, you will see a vertical line in the middle of the screen which can help you align the vessel. If your vessel is aligned properly, when you insert the needle right where the vertical mark on the probe is, you will be directly above the vessel. Ensure that the needle is directly perpendicular to your probe marker (the length of the probe and the length of the needle should make a T). 

Cannulate: There are two cannulation techniques, the triangulation technique where you will insert the needle at a 45 degree angle, and the near vertical technique in which you will insert the needle at a 90 degree angle. Throughout the entire cannulation period, you will be aspirating. Penetrate the skin as your aspirate. Then, slowly move your probe away from you until you see your needle tip. Either move your probe or your needle, do not move both at the same time. Once you see your needle tip, start to advance your needle until you can no longer visualize your needle tip on the screen. Now, advance your probe again away from you until you see your needle tip reappear. Repeat this process until you penetrate the vessel, see the needle tip within the center of the vessel lumen, and you have blood accumulating in your syringe with good flow while aspirating. Now you may drop the probe. Flatten your needle angle. Aspirate again to ensure good blood flow, and remove the syringe from the needle. When you remove the syringe, you should see pulsatile blood flow, if you don’t see this you may be in the femoral vein. 

Guidewire: Thread the guidewire over the needle. The guidewire has a J tip thus in order to thread it through, you must pull back slightly to straighten the tip. If you are meeting resistance, do not keep threading and re-check your position with the ultrasound, as there is risk of lacerating the vessel. You can trouble shoot by aspirating to ensure good flow, and pulling back on the introducer needle as you may be against the vessel wall. 

Confirm: Using the ultrasound, confirm your guidewire position in the artery in both the short and long axis view. Track the guidewire into the artery and ensure your tip is the center of the lumen. Capture pictures using the ultrasound to include in your procedure note.

Remove the needle: Remove the needle leaving the guidewire in place. 

Catheter Insertion: Feed the catheter through the guidewire and into the vessel. When you see the guidewire exiting the distal end of the catheter, pull out the guidewire.

Connect: Obtain the arterial tubing from the nurse and screw it onto the newly placed catheter. Ensure the catheter is reading accurately with a proper arterial waveform. 

Secure: Hub the catheter where it exits the skin with the biopatch, ensure the biopatch is against the patient’s skin. You will suture both ends of the winged portion of the catheter individually to the patient. Clean and dry the site, and then apply the sterile dressing.

Document: Write a procedure note including any complications or medications given during the procedure.